Journal of Acute Disease (2015)59-62 59

Contents lists available at ScienceDirect

Journal of Acute Disease

journal homepage: www.jadweb.org

Document heading doi: 10.1016/S2221-6189(14)60085-8

Hypoglycemia in Emergency Department

Yu-Jang Su1,2*, Chia-Jung Liao1
Department of Emergency Medicine, Mackay Memorial Hospital, Taipei, Taiwan
1

Department of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
2

ARTICLE INFO ABSTRACT

Article history: Objective: To study the epidemiology, etiologies and prognostic factors of hypoglycemia.
Received 14 Jan, 2015
Methods: A retrospective chart review of hypoglycemic cases from December, 2009 to February,
Revised 16 Jan, 2015
2012 was conducted to gather the following patient data: age, gender, vital signs at triage,
Accepted 18 Jan, 2015
white blood cell count, serum glucose, C-reactive protein, glutamic oxaloacetic transaminase,
creatinine, sodium, potassium, past history of liver cirrhosis, uremia, concomitant infection,
Keywords: concomitant cancer/malignancy, length of stay, lack of recent meal, status of acute renal failure
Hypoglycemia and concomitant stroke. A total of 186 cases were enrolled in our study. We analyzed the data
Liver cirrhosis using commercial statistics software (SPSS for Windows, version 11.0, SPSS Inc., Chicago, IL). We
Acute renal failure used the Student's t-test and χ2 test for the statistical analyses, and significance was set at a P
Infection
value less than 0.05.
Mortality rate
Results: Hypoglycemia is related to several co-morbidities. In total, 10.2% of the patients had
liver cirrhosis and 7.0% had uremia. More than half (55.4%) were bacterial infection during
hospitalization. Acute renal failure accounted for 26.3% of the hypoglycemic episodes. In addition
to the etiology of infection, the lack of a recent meal accounted for 44.6% hypoglycemic episodes.
A total of 2.2% of the cases resulted from an acute cerebrovascular accident. Approximately 8.6%
were concomitant with malignancy.
Conclusions: When hypoglycemic patients present in the emergency department, physicians
should pay attention to the presence of infection, malignancy, liver diseases (liver cirrhosis and
biliary tract infection), and acute renal failure.

infection, chronic renal insufficiency, liver diseases, and

1. Introduction recurrent hypoglycemic episodes[1-3]. However, physicians
have seldom mentioned or studied the prognostic factors
Hypoglycemia is an endocrine emergency that can alter of hypoglycemia. W e studied hypoglycemia through a
the patient’s mental status, resulting in lethargy, confusion retrospective review of records from D ecember, 2009
and organ dysfunction. C ommon causes are a lack of to February, 2012 at a tertiary teaching medical center
adequate intake of food, chronic alcohol abuse, interactions in N orthern T aiwan. T he epidemiology, etiologies and
among medications, increased physical exertion and prognostic factors for hypoglycemia are discussed in our
overdose of medications (insulin/oral hypoglycemic agent). It report.
presents with a variety of symptoms, ranging from impaired
cognitive function to convulsions, coma and death. In the
past, there have been many articles describing the etiologies 2. Materials and methods
of hypoglycemia, including old age, lack of a recent meal,
A retrospective chart review of hypoglycemic cases
*Corresponding author: Dr. Yu-Jang Su, MD, Department of Emergency Medicine,
Mackay Memorial Hospital, Taipei, Taiwan; Department of Oral Hygiene, College of (serum glucose less than 60 mg/dL) from December, 2009 to
Oral Medicine, Taipei Medical University, Taipei, Taiwan.
E-mail: [email protected] February, 2012 was conducted to gather data on patient age,
60 Yu-Jang Su and Chia-Jung Liao/Journal of Acute Disease (2015)59-62

gender, heart rate, systolic blood pressure, diastolic blood above 65 years old. Leukocytosis was defined as a WBC count
pressure at triage, white blood cell count (WBC), serum above 10 000/μL. Elevated CRP was defined as a level above
glucose, C-reactive protein (CRP), glutamic oxaloacetic 0.8 mg/dL. Elevated GOT was defined as a level above 41 U/
transaminase (GOT), creatinine, sodium, potassium, past L. Elevated creatinine was defined as a level above 1.3 mg/dL.
history of liver cirrhosis, uremia, concomitant infection ARF was defined as a doubling of level of creatinine within one
[urinary tract infection (UTI) or pneumonia or biliary tract month. Neonatal and pediatric patients (age less than 18 year-
infection], concomitant cancer/malignancy, length of stay, old) were excluded. We analyzed the data using commercial
lack of a recent meal, status of acute renal failure (ARF), and statistical software (SPSS for Windows, version 11.0, SPSS
concomitant stroke. A total of 186 cases were enrolled in Inc., Chicago, IL). We used the Student’s t-test and χ test for
2

to our study, and we divided the patients into survival and statistical analyses, and significance was set at a P value less
mortality groups to compare the differences affecting the than 0.05.
prognosis of hypoglycemia. The survival group was defined
as the patients who survived until discharge. Concomitant
stroke indicates newly-onset stroke with hypoglycemic 3. Results
episode in this emergency department (ED) visit. All charts
reviewed with a paper-based manner. Data missed of 49 A total of 186 cases of hypoglycemia aged from 26 to 98
patients’ CRP values and 4 patients’ GOT levels were found. years old with an average age of 70.5±15.3 were encolled.
Only one case of 79 year-old female is out-of-hospital A mong these patients, 70 . 4 % were elderly ( 131 / 186 ) .
cardiac arrest case. All values were recorded on patients’ A pproximately 45 . 2 % ( 84 / 186 ) had leukocytosis, which
arrivals of ED. indicated that a possible inflammatory process was involved
Patients with serum glucose levels less than 60 mg/dL were in the hypoglycemia. High CRP levels were noted in 82.8%
defined as hypoglycemic. Elderly age was defined as an age (154/186) of the cases. About 62.4% (116/186) had impaired

Table 1
Basic information of patients with hypoglycemic cases conducted from December, 2009 to February, 2012 in Northern Taiwan.
All Survival Mortality P value
Age 70.5依15.3 70.5依15.1 70.3依17.2 0.1980
M: F 96:90 82:83 14:07 0.000*
BT ℃ 36.4依1.2 36.4依1.1 36.3依1.4 0.087
HR /min 86.5依18.1 85.3依15.9 95.7依29.5 0.001*
SBP mmHg 139.3依30.0 141.7依27.3 120.0依41.2 0.286
DBP mmHg 73.3依18.1 74.6依16.9 63.7依23.8 0.079
WBC (/μL) 11 223.0依7 198.0 10  969.0依6 438.0 13 219.0依11 608.0 0.008*
Glucose(mg/dL) 34.9依12.4 35.1依12.0 33.1依15.6 0.026*
CRP (mg/dL) 5.1依6.5 4.7依5.4 9.1依13.1 0.008*
GOT (U/L) 110.0依340.0 82.2依312 324.0依461.0 0.001*
Creatinine (mg/dL) 2.8依2.6 2.8依2.6 2.9依2.9 0.837
Na (meq/L) 134.5依11.1 134.8依11.1 131.8依11.2 0.274
K (meq/L) 4.1依1.0 4.0依1.0 4.7依1.2 0.185
LOS (days) 15.2依18.9 14.6依16.0 20.2依34.3 0.022*
Liver cirrhosis 19/186 (10.2%) 12/165 (7.3%) 7/21 (33.3%) 0.000*
Uremia 13/186 (7.0%) 11/165 (6.7%) 2/21 (9.5%) 0.348
With Infection 103/186 (55.4%) 89/165 (54.0%) 14/21 (66.7%) 0.001*
UTI 62/186 (33.3%) 54/165 (32.7%) 8/21 (38.1%) 0.394
Pneumonia 43/186 (23.1%) 36/165 (21.8%) 7/21 (33.3%) 0.051
BTI 5/186 (2.7%) 3/165 (1.8%) 2/21 (9.5%) 0.000*
Lack Ingestion 83/186 (44.6%) 71/165 (43.0%) 12/21 (57.0%) 0.976
ARF 49/186 (26.3%) 39/165 (23.6%) 10/21 (47.6%) 0.006*
With cancer 16/186 (8.6%) 11/165 (6.7%) 5/21 (23.8%) 0.000*
With CVA 4/186 (2.2%) 3/165 (1.8%) 1/21 (4.8%) 0.088
BT: Body temperature; HR: Heart rate; SBP: Systolic blood pressure; DBP: Diastolic blood pressure; WBC: White blood cell count; CRP:
C-reactive protein; GOT: Glutamic oxaloacetic transaminase; LOS: Length of stay; UTI: Urinary tract infection; BTI: Biliary tract infection; ARF:
Acute renal failure; CVA: Cerebrovascular disease; *: P<0.05, significant difference.
 Yu-Jang Su and Chia-Jung Liao/Journal of Acute Disease (2015)59-62
61

renal function and 38.2% (71/186) had elevated GOT. hypothermia when hypoglycemia occurred. Approximately
Hypoglycemia was associated with several comorbidities. 11 . 3 % ( 21 / 186 ) of the hypoglycemic patients were
About 10.2% (19/186) had liver cirrhosis, and 7.0% (13/186) hypothermic in our study.
of the patients had uremia. More than half of the patients There were several precipitating factors contributing to
(55.4%) were infected during hospitalization. About 33.3% hypoglycemia, including the lack of a recent meal (44.6%-
(62/186) had UTIs and 23.1% (43/186) had pneumonia and 52 . 0 %) , alcohol consumption ( 21 . 0 %) , the presence of
2.7% (5/186) had biliary tract infections. ARF accounted for coronary artery disease, concomitant infection, CVA, or ARF,
26.3% (49/186) of the hypoglycemic episodes. malignancy and recent hospital discharge[2,5-8]. In our study,
In addition to the etiology of infection, the lack of recent concomitant infection (55.4%) was more commonly observed
meal accounted for 44.6% (83/186) of the hypoglycemic than the lack of a recent meal (44.6%). UTI (33.3%) was more
episodes. About 2.2% (4/186) of the cases resulted from an commonly observed than pneumonia (23.1%) and BTI (2.7%).
acute cerebrovascular accident (CVA). Approximately 8.6% In 1980, Dr. Miller described hypoglycemia as a warning sign
(16/186) were concomitant with malignancy. Overall in- of bacterial sepsis, and the mechanisms included depleted
hospital mortality rate was 11.3% (21/186). glycogen stores, impaired gluconeogenesis, and increased
In the male patients, tachycardia, elevated WBC, low glucose utilization by the infecting pathogens[9]. Clinically,
serum glucose, high CRP and GOT were associated with we observed several indicators, such as tachycardia,
an increased risk of mortality. Hepatic problems [liver elevated CRP , and elevated WBC , which implyed
cirrhosis and biliary tract infection (BTI)] concomitant with inflammatory processes in the patients. For hypoglycemic
malignancy, infection and ARF were also associated with patients with tachycardia, high CRP, and elevated WBC, the
higher mortality (Table 1). In the cases with concomitant mortality rate increased by 4-, 2- and 1.1-fold compared
malignancy, gastrointestinal tumors (5.4%) were the most with normal cardiac patients and those with normal CRP and
commonly observed, and lung cancer (2.2%) was the second WBC levels. Higher CRP levels were found in the mortality
most common extraintestinal tumor in hypoglycemic patients group of hypoglycemic patients than in the survivor group
(Table 2). (9.1 vs. 4.7, P=0.008<0.05). Up to 82.8% of hypoglycemic
Table 2 patients had elevated CRP levels, indicating concomitant
Hypoglycemic patients with malignancy.
infection or other tissue damage when the hypoglycemia
Gastrointestinal 10/186 (5.4%) Hypopharyngeal 1
Esophagus 1 occurred. These hypoglycemic patients with concomitant
Stomach 4 infection were recommended for hospitalization.
Hepatocellular 2 The diagnosis of hypoglycemia relies on blood tests. If
Cholangiocarcinoma 1
Rectum 1 the patient is critically ill, a rapid glucose test is a good
Lung 4/186 (2.2%) way to know whether hypoglycemia is present. To collect
Breast 1/186 (0.5%) data on liver and renal function, CRP, WBC, urine analysis,
Bladder 1/186 (0.5%)
and chest X-ray are all necessary to exclude infection and
determine the severity and prognosis. If there is a neurologic
deficit a few hours after intravenous dextrose administration,
4. Discussion a neurologist should be consulted to exclude stroke.
Although there was a small fraction (8.6%) of hypoglycemic
Hypoglycemia is a life-threatening emergency. It can with patients with concomitant malignancy, more than half
lead to various forms of cognitive dysfunction and death. of the malignancies originated from the gastrointestinal
Hypoglycemia occurs most frequently in the elderly. In tract. Others sites of origin included the lungs, breast and
our study, 70.4% of the cases were over 65 years old[4,5]. bladder. The general status of a reduced appetite in patients
In a Korean report conducted in 2012, the mean age of with cancer involving the gastrointestinal system led to
hypoglycemic patients was 69.5 years old, similar to our hypoglycemia.
study ( 70 . 5 years old ) [1]. W ith respect to gender, there C omorbidities related to hypoglycemia are impaired
was no significant difference in the case distribution. renal function and hepatic diseases[1,3]. In our study, 62.4%
Some hypoglycemic patients exhibited cold sweating and of the hypoglycemic patients had impaired renal function
62 Yu-Jang Su and Chia-Jung Liao/Journal of Acute Disease (2015)59-62

and 26 . 3 % of patients had ARF at the time of the References

hypoglycemic episode. A G erman report in 2 0 0 3
reported that 54 . 0 % of the hypoglycemic patients [1] Ha WC, Oh SJ, Kim JH, Lee JM, Chang SA, Sohn TS, et
had renal impairment. A nother report from S outhern al. Severe hypoglycemia is a serious complication and
T aiwan in 2006 reported that 5 . 7 % hypoglycemic becoming an economic burden in diabetes. Diabetes Metab J
p a t i e n t s h a d e x t e n s i v e l i v e r d i s e a s e [3,10]. 2012; 36(4): 280-284.
H ypoglycemic patients with liver cirrhosis and BTI [2] Lin YY, Hsu CW, Sheu WH, Chu SJ, Wu CP, Tsai SH. Risk
had 9 . 6 - and 3 . 2 -fold higher mortality rates compared factors for recurrent hypoglycemia in hospitalized diabetic
to those without liver problems in our study. patients admitted for severe hypoglycemia. Yonsei Med J
In the treatment of hypoglycemic patients, 2010; 51(3): 367-374.
intravenous dextrose ( 1 gm/kg body weight ) is rapidly [3] S u CC. Etiologies of acute hypoglycemia in a Taiwanese
effective within a few minutes after administration. hospital emergency department. J Emerg Med 2006; 30(3):
I f a patient presents with a serum glucose level less 259-261.
than 60 mg/d L and impaired mental status without [4] L eese GP, Wang J, Broomhall J, Kelly P, Marsden A,
alertness, the administration of dextrose water is Morrison W, et al. Frequency of severe hypoglycemia
necessary. S erial determination of serum glucose requiring emergency treatment in type 1 and type 2 diabetes:
level is mandatory. a population-based study of health service resource use.
Hypoglycemia is related to several vascular Diabetes Care 2003; 26(4): 1176-1180.
diseases, such as coronary artery disease, stroke and [5] Arinzon Z, Fidelman Z, Berner YN, Adunsky A. Infection-
peripheral arterial diseases[11] . I n our study, 2 . 2 % of related hypoglycemia in institutionalized demented patients:
hypoglycemic patients presented with CVA at the time a comparative study of diabetic and nondiabetic patients.
of the hypoglycemic episodes. I n such a situation, Arch Gerontol Geriatr 2007; 45(2): 191-200.
intravenous dextrose fluid could not alleviate the [6] Feher MD, Grout P, Kennedy A, Elkeles RS, Touquet R.
neurologic deficit due to the initial hypoglycemia. Hypoglycaemia in an inner-city accident and emergency
T he overall mortality rate of hypoglycemic patients in department: a 12-month survey. Arch Emerg Med 1989;
our study was 11 . 3 % . 6(3): 183-188.
When hypoglycemic patients are encountered in the [7] Shorr RI, Ray WA, Daugherty JR, Griffin MR. Incidence
ED, physicians should consider the presence of infection, and risk factors for serious hypoglycemia in older persons
malignancy, liver disease ( liver cirrhosis, biliary tract using insulin or sulfonylureas. Arch Intern Med 1997;
infection) and ARF. It is important to further examine possible 157(15): 1681-1686.
inflammatory processes and consider the possibility of [8] Waeschle RM, Moerer O, Hilgers R, Herrmann P, Neumann
deteriorated renal function in hypoglycemic patients. P, Quintel M. The impact of the severity of sepsis on the risk
We can not define ARF in patients who have no medical of hypoglycaemia and glycaemic variability. Crit Care 2008;
records in the same hospital before their ED visits in our study. 12(5): R129.
This could be a bias in number of ARF patients. Data missed of [9] Miller SI, Wallace RJ Jr, Musher DM, Septimus EJ, Kohl S,
49 patients’ CRP values and 4 patients’ GOT levels were found. Baughn RE. Hypoglycemia as a manifestation of sepsis. Am
Only one case of 79 year-old female is out-of-hospital cardiac J Med 1980; 68(5): 649-654.
arrest case. This study is based on data of single center in [10] H o l s t e i n A , P l a s c h k e A , E g b e r t s E H . C l i n i c a l
Northern Taiwan. The conclusion might be different in national characterisation of severe hypoglycaemia-a prospective
registry or including cases from Southern Taiwan. These are all population-based study. Exp Clin Endocrinol Diabetes 2003;
influenced factors in data analyses. 111(6): 364-369.
[11] Gitt AK, Bramlage P, Binz C, Krekler M, Plate T, Deeg E,
et al. Hypoglycaemia is more frequent in type 2 diabetic
Conflict of interest statement patients with co-morbid vascular disease: an analysis of the
DiaRegis registry. Eur J Prev Cardiol 2012; 19(4): 765-772.
T he authors report no conflict of interest.